Provider Demographics
NPI:1629748512
Name:MONTAGUE, MARIAH SHELBY (BS, RBT, QMHP-T)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:SHELBY
Last Name:MONTAGUE
Suffix:
Gender:F
Credentials:BS, RBT, QMHP-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 SHADY TREE CT
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23238-3442
Mailing Address - Country:US
Mailing Address - Phone:804-382-0806
Mailing Address - Fax:
Practice Address - Street 1:1750 SHADY TREE CT
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23238-3442
Practice Address - Country:US
Practice Address - Phone:804-382-0806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-21-184521106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician